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BACKWATER PREVENTION DEVICE FINAL <br />4M77 INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: 12/1f,-4 TIe/ /S�7 <br />Date Backwater Prevention device (BWD) was installed: /S Date/this form was completed: / / >r <br />Installation Property Owner Name and Contact Info: ,,yeSS l e-/2 ILE— elS <br />Properly Address: 7/r/ /Ao y T ,6VeI4,? / L^ A ^L" / <br />Pre -installation Inspection Checklist: <br />All items must he checked'Yes' in order for a BIND to he considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? Wyes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation?,Z Yes ❑ No <br />Is the -side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? FZYes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' be%re inspection is considered complete <br />Was side sewer N inspected from building to sewer main? ,Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? 0 `'es ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? Wes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? 2rYes []No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? Z Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this sit can Che , rinder pump, etc.): _ <br />Where was the device installed (general description, attach map)? r a 13"S> /2 <br />JZ�n <br />. Jas there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? VYes [:]No Comments: <br />Does BWD positioning meets minimum slope requirement of>1%? OYes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ❑Yes ❑ No <br />Is BWD locked into the proper posif rew tightened? FZYes ❑ No <br />Circle the BWD co rigation cover (landsca eAr WIraffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown the location of t installed BWD? 2yes ❑ No Comments: <br />Properly Owner's Signal <br />Date: t2/2,/JY <br />Installer's Signature. Date: <br />Revision: 2 1 Friday, September 12, 2014 <br />